Treatment for Anxiety, Depression and Stress Disorders

Treatment

What is CBT?

Cognitive-Behavioral Therapy (CBT) is a form of psychotherapy that
emphasizes the importance of thinking in determining how we feel and
act. CBT is really an approach, rather than a single, specific treatment,
and there are many different treatment approaches and techniques that
full under the rubric of CBT.

Various names that you might hear that fall under the umbrella of CBT
include Acceptance and Commitment Therapy (ACT), Mindfulness-Based Cognitive
Therapy (MBCT) Meta-Cognitive therapy (MCT), and Rational-Emotive Therapy
(RET).

All of the various CBT approaches share many things in common. Treatment
is short-term, goal-oriented, and systematic. One of the central components
to all CBT approaches is to work with clients to help them to reduce
their symptoms and achieve more flexibility in their thinking, emotions
and behaviors. There are a number of specific techniques that we use
to achieve this goal, but the focus is on understanding and changing
the inter-relationships among thoughts, emotions, and behaviors.

How does CBT work?

From a CBT perspective, the problems that people bring to therapy result
from an interaction among biology (inherited temperament and characteristics
as well as developmental effects), learning history (the sum total of
life experiences), and current situation (what is happening right now
in their lives). As a result of these factors, people develop specific
styles of thinking, feeling and acting that may not be productive for
them and may lead to frustration, unhappiness or a host of specific symptoms
such as anxiety and depression. CBT can help you to change your style
of thinking, feeling, or acting, so that you have more flexibility in
how you experience your world and are thereby less likely to feel controlled
by your emotions and better able to live the life that you desire.

Recent research shows that changes that result from CBT may result in
permanent changes in your brain function and chemistry. Thus, the changes
that you make may be hard-wired, in much the same way that learning any
skill (e.g., playing a musical instrument) can lead to permanent changes
in your brain.

What will treatment be like?

CBT is a structured and goal-oriented approach. The first session or
two will be devoted to an evaluation and formation of a treatment plan.
The evaluation consists of an interview and may include some simple self-report
paper and pencil measures. Although I need to collect detailed information
about the history of your problem, as well as aspects of your developmental
history, I don’t spend a lot of time exploring issues from long ago because
treatment focuses on changing current patterns, rather than simply trying
to figure out how they began.

At the end of the evaluation, I will share with you my view of your
problem and how treatment can help. We will then work together to develop
clearly stated goals for treatment to ensure that your expectations and
what I am offering are closely aligned. After the initial visit (usually
90 minutes) we typically meet weekly for 50 minutes sessions. A specific
agenda is mutually agreed upon at the beginning of each session that
is based on your goals as well as your progress in therapy.

A central aspect of CBT is the use of homework assignments—some involve
reading or writing, others involve doing some specific task. These assignments
are focused on real-life application of the techniques that are learned
in therapy. A major focus of each treatment session is to review the
results of completed homework assignments and discuss what was learned
and how future assignments can be best structured.

During the course of treatment, we will continuously assess how you
and I view your progress and whether treatment is meeting your expectations.
Treatment is a collaborative process between patient and therapist, and
it works best when we both share a view of the work that has been completed
and what is left to accomplish.

How long will treatment last?

CBT is short-term therapy, relative to other therapies that can last
for several years (e.g., psychoanalytic therapy). Most clients see some
improvement relatively quickly and an average course of therapy is in
the range of 10 – 20 sessions. However, there is no set number of sessions
because treatment is tailored to each unique individual case. I work
collaboratively with each client to identify primary complaints, set
specific treatment goals, and to track progress toward goals. As treatment
progresses, adjustments are made to ensure that you receive treatment
that is optimized for your specific concerns.

The frequency of treatment sessions may change across time, beginning
with weekly sessions and moving to bi-weekly, monthly or less frequently
as progress is made. Many patients continue to meet with me intermittently
over a long term to prevent relapse and to maintain their gains. It is
said that the CBT therapist has many roles, beginning with therapist
and evolving to teacher, coach, advisor and, finally, consultant. We
will collaborate on the evolution of the relationship and how it is ultimately
structured.

Will I need medicine?

As a Clinical Psychologist, I do not prescribe medicine. However, we
have several psychiatrists on staff that can evaluate you and provide
medicine, if needed. We will decide, together, whether a consultation
for medicine is warranted. If you do receive medicine from one of our
psychiatrists, I will work closely with him so that we are both in agreement
about your treatment plan and your progress.

Treatment for anxiety disorders

There are several well-established CBT approaches for treating anxiety
disorders. Although the focus of treatment and specific techniques employed
vary somewhat across the different disorders (e.g., treatment for panic
disorders differs from treatment for obsessive-compulsive disorder or
generalized anxiety disorder) several aspects of treatment are consistent
across the anxiety disorders spectrum.

Two key concepts for understanding CBT for anxiety disorders are: a)
experiential avoidance, and b) exposure. Experiential avoidance (sometimes
described as fear of fear) is the attempt to avoid specific thoughts
and feelings that are uncomfortable. Panic disorder provides a good example
of how experiential avoidance can develop and be maintained.

Clients often report that panic attacks are so uncomfortable that they
will do almost anything to avoid having them. As a result, situations
and activities associated with panic attacks may be studiously avoided.
Avoidance works in the short-term because it keeps you out of situations
where you might feel anxious, and the avoidance behavior is thereby strengthened
(maintained by negative reinforcement). When avoidance becomes extreme,
clients are diagnosed with agoraphobia.

Exposure is a treatment approach that provides contact with the feared
object, situation, or thought that is causing distress. A classic CBT
approach is to develop a hierarchy of feared situations, teach some coping
and distress management skills, and to encourage gradual exposure to
the hierarchy via a set of structured behavioral exercises. One goal
of exposure exercises is for clients to learn that anxiety is not really
dangerous (although it is uncomfortable) and that they can learn to function
even with anxiety. A further goal of exposure is habituation to anxiety,
so that the intensity of symptoms is reduced, gradually, across time.

CBT also uses a variety of techniques for “restructuring” cognitions.
What this means is helping you change the way that you think. Some of
these techniques approach thinking directly, and we often spend time
talking about how strongly beliefs are held, discussing the evidence
base for beliefs, generating alternative explanations, as well as conducting
mini experiments to test beliefs.

Exposure also has an impact on beliefs. Learning that you can function
in feared situations and that no irreparable harm occurs, results in
a revised perception of the things that you fear. Maybe they are not
as dangerous or terrifying as you once believed.

Some of the newer CBT approaches incorporate “mindfulness” and “acceptance” based
techniques. These techniques also use exposure type exercises, but they
differ somewhat from the classic CBT approach by teaching that the experience
of anxiety, although it may be uncomfortable, does not necessarily need
to be reduced in order for clients to live happy, fulfilled lives. Thus,
there is more of an emphasis on re-interpreting or “deconstructing” anxiety
as a normal part of everyday life, and less of an emphasis on attempts
to reduce specific symptoms. We talk about helping clients change their “relationship
with their thoughts.”

An important aspect of this approach is learning to recognize, understand,
and manage “metacognitions.” The term Metacognition refers to thoughts
about thoughts and styles of thinking and processing information. What
does it mean if you have fears and anxieties? Consider a person who experiences
a rapid heart rate in a social situation and has the thought “I acted
like an idiot; I am so embarrassed.” If the symptom and the thought
are simply dismissed as something that happened and no big deal, the
event is unlikely to be remembered and unlikely to cause significant
distress. If, however, the event results in a focus on figuring out “what
is wrong,” and attempts to prevent it from happening again, it may be
an early step in the development of social anxiety disorder.

Treatment for obsessive-compulsive disorder

Cognitive-behavioral treatment of obsessive-compulsive disorder (OCD)
is referred to as exposure with response (or ritual) prevention (ERP).
Obsessions are thoughts, often related to some specific fear (e.g., fear
of contamination by germs or fear for the health of a loved one), and
rituals are behavioral or mental acts that serve to reduce the anxiety
generated by the obsessions. The goal here, as with treatment for other
anxiety disorders, is to induce clients to remain in contact with the
feared object/situation/context or uncomfortable thought and to not engage
in any rituals that will reduce the anxiety. Over time, anxiety will
diminish naturally and the OCD will weaken, making it easier for clients
to function, even if some low-level symptoms remain.

Treatment for depression

Depression is a complex disorder composed of a tightly-linked pattern
of thoughts, feelings, and behaviors. Many years ago Aaron Beck identified
the “cognitive triad” that is characteristic of depressive thinking:
negative thoughts about the self, the world, and the future. However,
thinking is not the whole story. As depression becomes chronic, the link
between thinking, feeling, and behavior becomes ever stronger and difficulties
in any one area can trigger the entire syndrome. Treatment focuses on
breaking the links among thoughts, feelings, and behaviors, thereby changing
the underlying pattern. I will work with you to determine the most efficient
and effective way to approach your depression. In some cases we will
focus initially on changing thoughts; in other cases we will focus on
behavior first (e.g., increasing activity) and observe how thoughts and
feelings change as a result.

Treatment for stress disorders

Treatment for stress disorders involves a combination of problem-solving
strategies and learning how to think about situations in a different
way. I will help you to identify clearly the stressors in your life and
to formulate an approach to cope with them more effectively. In some
cases, we will focus on changing situations that are causing distress
(e.g., by learning how to be more assertive). In other cases situations
may not be changeable (e.g., dealing with a chronic illness), and we
will focus on working with your thoughts and reactions to the situation.